Why Chiropractic Is Controversial (1990)

William T. Jarvis, Ph.D.

Chiropractic is a controversial health-care system that has
been legalized throughout the United States and in several other
countries. In the United States in 1984, roughly 10.7 million
people made 163 million office visits to 30,000 chiropractors
[1]. More than three fourths of the states require insurance companies
to include chiropractic services in health and accident policies.
The federal government pays for limited chiropractic services
under Medicare, Medicaid, and its vocational rehabilitation program,
and the Internal Revenue Service allows a medical deduction for
chiropractic services. Chiropractors cite such facts as evidence
of "recognition." However, these are merely business
statistics and legal arrangements that have nothing to do with
chiropractic's scientific validity.

Although it has existed for nearly 100 years, the chiropractic
health-care system has failed to meet the most fundamental standards
applied to medical practices: to clearly define itself and to
establish a science-based scope of practice. More disturbing is
the fact that chiropractic has made no contribution to the worldwide
body of knowledge shared by the health sciences and continues
to isolate itself from the mainstream of the health-care community.

Spinal Manipulative Therapy (SMT)

An estimated 80% of adults will experience a severe bout with
back pain and dysfunction at some time in their life. There is
substantial evidence that spinal manipulative therapy (SMT) has
value in relieving back pain and improving the range of impaired
spinal motion at least temporarily. Although SMT is probably no
more effective than other modalities in the long term, it appears
to offer faster relief in about one third of patients [2-4] Further,
because SMT involves the laying on of hands, a technique widely
employed throughout history by folk and faith healers, it enhances
suggestibility and the placebo effect [5,6]. Many people like
SMT because of the direct contact it involves and the subjective
relief it brings. Charles DuVall, Sr., D.C., reports that SMT
can become addictive [7].

Chiropractic is commonly thought to be synonymous with SMT.
In reality, SMT's history goes back at least to Hippocrates (400
B.C.), while chiropractic's roots go back less than 100 years.
Folk healers ("bonesetters") and early osteopaths used
SMT as a panacea. Today SMT is employed by medical specialists
(physiatrists, orthopedists, sports medicine practitioners), osteopathic
physicians, physical therapists, and athletic trainers, as well
as by chiropractors.

A survey of back-pain sufferers revealed that physiatrists
are the most effective at treating back problems [8]. Physiatrists
are medical doctors who specialize in rehabilitation. Formerly
they were called doctors of physical medicine. But physiatrists
are few in number and can be difficult to find. (They often practice
in connection with Veterans Administration hospitals.) Some hospitals
now have back treatment centers that emphasize strengthening weak
stomach musculature (a major cause of back problems) and improving
the flexibility of the back. Many of these centers offer SMT either
by a physical therapist or a chiropractor.

Chiropractors are the SMT practitioners most accessible to
the public, and 85% of people who patronize them do so for neuromusculoskeletal
problems [1]. Chiropractors point with pride to selected worker's
compensation studies that show that chiropractic care got workers
back on the job sooner and for less cost than did medical care.
But these studies were not scientifically controlled for the severity
of the injuries, and not all workmen's compensation studies have
been favorable to chiropractic. Nonetheless, the studies do suggest
that chiropractors can play a useful role in treating workers
with musculoskeletal problems.

Chiropractic's Unique Theory

Chiropractic's uniqueness lies not in its use of SMT, but in
its theoretical reason for doing so. just as prescientific osteopathy
found its justification in the "rule of the artery"
(the belief that manipulation improved circulation by reducing
muscle spasms), chiropractic is based upon the "rule of the
nerve" (the belief that SMT has important effects upon "nerve
flow").

Obsessed with uncovering "the primary cause of disease,"
Palmer theorized that "95 percent of all disease" was
caused by spinal "subluxations" (partial dislocations)
and the rest by "luxated bones elsewhere in the body."
Palmer speculated that subluxations impinged upon spinal nerves,
impeding their function, and that this led to disease. He taught
that medical diagnosis was unnecessary, that one need only correct
the subluxations to liberate the body's own natural healing forces.
He disdained physicians for treating only symptoms, alleging that,
in contrast, his system corrected the cause of disease.

Palmer did not employ the term subluxation in its medical sense,
but with a metaphysical, pantheistic meaning. He believed that
the subluxations interfered with the body's expression, of the
"Universal Intelligence" (God), which Palmer dubbed
the "Innate Intelligence." (soul, spirit, or spark of
life). [9] Palmer's notion of having discovered a way to manipulate
metaphysical life force is sometimes referred to as his "biotheology."

Scientific Shortcomings

Chiropractors commonly claim that their isolation from the
health science mainstream results from organized medicine's opposition.
Chiropractic propagandists have made much of a 1987
court decision that found the American Medical Association
and others guilty of illegally boycotting chiropractors. But the
Wilk case did not uncover any secret conspiracy by doctors to
destroy chiropractic. It merely examined whether or not the AMA's
ethical prohibition against voluntary professional association
with nonscientific healthcare providers violated the Sherman Antitrust
Act. On August 27, 1987, District judge Susan Getzendanner decided
that it did. She stated in her decision, however, that the AMA's
ethical prohibition was not economically motivated, but was based
upon the AMA's belief that chiropractic care was did not serve
the best interest of patients [10]

Palmer can be forgiven for his nineteenth-century misconceptions,
but his followers cannot be excused for failing to avail themselves
of the scientific advances of the twentieth century to test chiropractic
theory and practice. In fact, chiropractors have never defined
a subluxation in measurable terms, nor shown that it even exists.
Despite the ability of neurophysiologists to measure nerve impulses,
chiropractors have not shown that impinging a spinal nerve alters
an impulse beyond the zone of impingement, nor have they shown
that disrupting a nerve impulse produces disease. Yale University
anatomist Edmund Crelin, Ph.D., demonstrated that only a disabling
spinal injury could produce the impingement that Palmer posited
as the basis for chiropractic [11].

But laboratory failings do not daunt chiropractors. They argue
that no one fully understands the mechanisms of many effective
medical procedures. As clinicians they feel capable of detecting
subluxations subjectively, even if objective methods for doing
so are lacking. However, chiropractors have yet to pass a test
of interexaminer reliability. Studies of the ability of two or
more chiropractors to find the same subluxation(s) on either the
same x-ray film or in the same patients have demonstrated that
chiropractors cannot even agree among themselves about what specific
conditions need treatment [12-16].

In the mid-1960s, an official delegation of chiropractic representatives,
including a radiologist of their own choosing, failed
to identify a single subluxation on a series of 20 x-ray films
that had been submitted for insurance reimbursement to the National
Association of Letter Carriers [14]. In 1972, the Medicare law
was amended to include chiropractic care for "subluxations
demonstrated by x-rays to exist." A 1986 report by the
Inspector General of the Department of Health and Human Services
revealed that many payments for chiropractors do not meet this
legal requirement [17]. The fact that the federal government does
not enforce the rules it has established for chiropractors raises
the question of a double standard. Is there one standard for science-based
medicine and another for nonscientific practitioners with political
savvy?

Chiropractors not only find subluxations as elusive as the
mythical unicorn, but they also disagree wildly about how to go
about treating them. Some believe that each vertebral level corresponds
to a specific disorder. Others believe that it is necessary to
manipulate only the seven cervical vertebrae to effect a cure.
"Hole-in-one" (their term) practitioners believe that
it is necessary to adjust only the atlas (topmost) vertebra. Basic
sacral chiropractors agree that only one vertebra needs to be
adjusted, but rather than the topmost, it is the sacrum, located
at the bottom of the spine. Still another group adjusts both the
atlas and sacral vertebrae. Others adjust the entire spine in
a shotgun approach, while another group measures leg lengths in
order to level up the spine. No scientific criteria have been
applied to resolve these conditions.

Anyone visiting a number of chiropractors will be confronted
with a bewildering variety of pseudoscientific diagnostic procedures.
In 1981 Mark Brown, a reporter for the Quad City Times,
spent five months visiting chiropractors in the Davenport, Iowa,
area (the birthplace of chiropractic). Diagnostic methods included
placing a potato on his chest and pressing down on his arm (applied kinesiology), projecting lines
on his back to read body contours (Moire contour analysis), reading
the iris and comparing markings with a chart (iridology), measuring
leg lengths for unevenness (one chiropractor said Brown's right
leg was shorter, another said his left leg was shorter) , measuring
skin surface temperature differences, and palpation [16]. Other
dubious diagnostic methods used by some chiropractors include
pendulum divining, electroacupuncture, reflexology, hair analysis,
herbal crystallization analysis, computerized "nutritional
deficiency" questionnaires, a cytotoxic food allergy test,
and the Reams urine and saliva test.

Chiropractors also employ a wide variety of pseudomedical therapies.
Magnetic therapy (placing magnets on the body), homeopathy, herbology,
colonics, colored-light therapy, megavitamin therapy, radionics
(black box devices), bilateral nasal specifics (inserting a balloon
in the nose and inflating it), and cranial manipulation are but
a few of the unfounded therapies employed by various chiropractors.

A 1988 trade survey found that 74% of chiropractors in the
United States use nutrition supplements in their practices [18].
Many prescribe and sell these directly to patients -- a practice
that is generally regarded as unethical in the medical profession.

Chiropractors promote themselves as "drugless practitioners,"
capitalizing on the restrictions against the use of drugs or surgery
that lawmakers have placed upon them. The word drug has several
definitions. Included are: articles listed in several recognized
official United States pharmacopoeias; articles intended for use
in the diagnosis, cure, mitigation, treatment, or prevention of
disease in man or animals; articles (other than food) intended
to affect the structure or any function of the body [19]. In 1987
the supreme court of Georgia ruled that because chiropractors
were licensed as drugless practitioners, they could not prescribe
dietary supplements for the prevention or treatment of any condition.
Not long afterward, the legislature reacted to chiropractic lobbying
by passing a law permitting chiropractors to recommend dietary
supplements to their patients, but not to prescribe them as drugs.

The use of x-rays by chiropractors is a related issue. Chiropractors
often expose the whole body trunk to x-ray radiation. Since radiation
effects are cumulative, exposing patients to radiation always
involves a serious benefit-risk evaluation. Chiropractors often
justify their use of X-rays as a means of screening patients for
serious disease, but a recent probability study by a chiropractic
radiologist reveals that full-spine x-rays are twice as likely
to induce cancer as to discover it in a patient [20].

One thing chiropractors excel at is satisfying their patients.
Patients rank them above medical doctors in the concern exhibited
about their problems, understanding their concerns, amount of
time spent listening to a description of their pain, information
provided about the cause of their pain, making them feel welcome,
and other factors related to the art of fulfilling human needs
[21,22]. Although it is important for physicians to differentiate
between mere patient satis, faction and true clinical effectiveness,
it seems that they could learnsomething from chiropractors about
meeting the emotional needs of suffering patients.

Factions in Chiropractic

Only a minority of today's chiropractors adhere to Palmer's
"one-cause-one-cure" theory, but most still believe
that subluxations exist and may play an important role in the
cause and treatment of diseases. Chiropractors who wish to be
considered full-fledged physicians consider limiting the value
of SMT merely to relieving pain and improving function as an affront.

Practitioners who limit their practices to analyzing the spine
and correcting subluxations are called "straight" chiropractors.
Those who believe that they are affecting Palmer's biotheological
"Innate Life Force" are often called "superstraights."
The straights label chiropractors who do more than SMT "mixers,"
because they mix other modalities. These various chiropractic
factions have been at odds with each other throughout nearly all
of chiropractic's existence. Each claims to be the true chiropractors
and labels the others as cultists or "pseudomedical doctors."
The strife between these factions has been fought out in courts
and state legislatures and remains unresolved to this day.

Often the straight/mixer dichotomy is wrongly suggested as
a useful criterion for separating rational from irrational practitioners.
In fact, either type can be irrational. Straights may be cultists
who overuse SMT, applying it to conditions for which it offers
no benefit. And mixers have a propensity for espousing pseudomedical
fads and are probably the major sources of nonsensical modalities
in the health-care marketplace. Both straights and mixers have
traditionally opposed scientifically based public health measures
such as immunization, fluoridation, pasteurization of milk, modern
food technology, prescription drugs, and surgery.

The Reformers

Among the newer factions are several reform groups. One group
publishes the Journal of Manipulative and Physiologic Therapeutics,
which is indexed by Index Medicus. They publish results of tests
of various modalities, and they publish articles dealing with
chiropractic's scientific inadequacies. They hope to reform chiropractic
quietly from within.

A more outspoken group, the National Association for Chiropractic
Medicine (NACM), is composed of chiropractors who use only SMT
and treat only functional back disorders that are not disease-related.
NACM believes that chiropractic pseudomedicine and cultism are
too well entrenched, and that the moral responsibility for public
well-being is too serious to merely hope and patiently wait for
self-reform. NACM members publicly renounce the subluxation theory
and other forms of chiropractic pseudomedicine. They do not present
chiropractic as an alternative to regular medicine, but offer
their skills as SMT specialists in cooperation with mainstream
medicine.

Reformers have a difficult time because they find themselves
ostracized by the chiropractic guild for breaking ranks and openly
criticizing chiropractic, but they may have difficulty being accepted
by regular medical practitioners. These reformers, particularly
NACM's leaders, exhibit rare, selfless courage. The first outspoken
reformer, Samuel Homola, D.C., published his observations in 1963
in Bonesetting, Chiropractic, and
Cultism, which is posted on this Web site.]

The dilemma reformers face is that chiropractors do not perform
any service or deal with any condition not covered by some other
health profession. State laws that enable them to practice either
specifically mention the subluxation theory or describe it as
the basis for chiropractic as an entity. Renouncing chiropractic's
theoretical basis would eliminate its justification for existing
as a separate profession.

Reformers acknowledge that they offer mainly the specialized
skill of SMT. They believe that SMT is underutilized and that
a substantial market exists for their skills. Although other health
professionals can legally perform SMT or treat functional back
disorders, most do not. To become skilled at SMT requires more
time and effort than most physicians or physical therapists are
willing to invest, especially when they feel that they may achieve
the same clinical results over the long term with less demanding
modalities.

Consumer Guidelines

The SMT skill of chiropractors varies among individual practitioners.
Chiropractic is a cottage industry without an arena that permits
critical peer review like that hospitals provide for medical doctors.

When evaluating a chiropractor's claims, it is useful to ask
him or her what diseases chiropractic adjustments cannot benefit.
A rational practitioner will readily admit to great limitations
in treating anything other than musculoskeletal problems. A less
rational chiropractor may answer by dodging the question with
a response such as "I treat only people who have spines,"
or "I don't treat diseases; I treat people." Such answers
avoid the question and/or represent a belief in the subluxation
theory.

There is no agency that can tell how good an individual chiropractor
is as a spinal manipulative therapist. Consumers must generally
rely upon the practitioner's local reputation. When choosing a
chiropractor, consumers should exercise great caution and consider
the following guidelines.

1. Have the problem evaluated by a medical doctor first.
Have underlying serious illnesses ruled out before deciding that
the problem is neuromusculoskeletal. Heart disease, cancer, kidney
dis' ease, and other serious problems that need prompt medical
care may manifest themselves as back pain and dysfunction. Don't
allow an overzealous, inadequately trained chiropractor to keep
you from prompt diagnosis and care. If the chiropractor recommends
X-rays, have them done by a radiologist.

2. If you decide to try SMT, inform your doctor. Ask
if there is any reason you should not have SMT (osteoporosis is
one common contraindication). if not, ask for his or her help
in locating the most skillful practitioner in the area (physiatrist,
physical therapist, chiropractor, etc.). Some doctors feel that
SMT hasn't been scientifically proven effective, but most are
willing to go along with a patient who wishes to give it a try.

3. Remember that the main value of SMT lies in the rapidity
of the relief it provides. If you have not experienced significant
relief within three weeks, discontinue SMT. Do not submit to long-term
care. Do not sign a contract. And do not accept the idea of preventive
chiropractic care. Education about how to prevent back problems
by safe lifting techniques, proper exercise, and ergogenics (analyzing
and redesigning the workplace to avoid injuries) is valuable.

4. Avoid practitioners who:

Appear overconfident or cultist in their zeal for chiropractic
care

Disparage regular medicine as jealously antichiropractic

Criticize prescription drugs or surgery in an ideological
manner

Attack immunization, fluoridation, pasteurization, or other
public health practices

X-ray all of their patients, or routinely use full-spine
x-rays.

Use scare tactics such as claiming that the failure to undergo
chiropractic care could lead to serious problems in the future

Sell herbs or dietary supplements

Perform colonic irrigations. These have no medical value
and can be dangerous [23].

Claim that subluxations exist and that their correction is
important.

5. Children should not be treated by chiropractors.
There are no childhood conditions that chiropractors are better
qualified than physicians to treat.

References

1. Chiropractic: State of the Art. American Chiropractic
Association, 1986.